The introduction of cashless hospitalisation in insurance policies has helped people not to worry about cash while admitting their close ones in a hospital. With the help of this facility, patients can undergo any necessary treatment without the worry of direct payment. In case of cashless claims, the insurer settles all bills (if it does not exceed a sum insured amount) directly through coordination with the hospital without involving the policyholder.
Types of Cashless Hospitalisation
In India, there are three types of cashless hospitalisation facilities available:
1. Individual Cashless Medical Insurance Policy
Under this particular insurance policy, only the insured person can seek cashless benefits on seeking treatment from a network hospital.
2. Family Floater Cashless Health Insurance Policy
Individuals can cover themselves alongside their family members under a single health insurance policy. The cashless benefits are available to all the family members covered under this single plan.
3. Cashless Health Insurance Policy for Senior Citizens
This plan offers cashless benefits to senior citizen policyholders. The plan typically covers ambulance charges, hospital expenses, and various pre-existing ailments subject to policy terms and conditions.
Cashless Hospitalisation Benefits
The benefits of cashless hospitalisation are manifold. These include:
- Policyholders can do away with the hassle of arranging for funds during an emergency. Medical emergencies put a lot of emotional toll on individuals and their families. Cashless claims relieve policyholders from the financial burden of paying cash upfront to seek treatment.
- With most insurance providers shifting their operations to the digital platform, raising cashless claims have become hassle-free.
- Leading insurance providers have over 10,000 network hospitals across the country in India. This has made seeking such facilities much easier.
How does a Cashless Hospitalisation Function?
Health Insurance providers have an association with various private and Government hospitals in India. These firms first check the quality of services offered by these hospitals and then negotiate on prices before tying up.
These hospitals are known as network hospitals. On getting admitted to one of these hospitals, the expenses incurred in due course of seeking treatment are directly settled by an insurer.
1. Planned Hospitalisation
In this case, policyholders are aware of their hospitalisation in the upcoming days. In such a situation, follow the below-mentioned cashless hospitalisation process:
- First, check your policy or call the toll-free number to find a nearby network hospital.
- After shortlisting a network hospital, take a policy card to the hospital and get a pre-authorisation form. It is also possible to download a pre-authorisation form from the TPA (Third Party Administrator)’s website.
- A policyholder will have to fill the first part of the form, while a physician will fill the other part.
- Now, submit your form to the insurance desk.
- After that, the form will get faxed to the TPA.
- A TPA will approve or reject your form.
- In case of approval, the TPA will send an authorisation letter mentioning a sanctioned amount.
2. Emergency Hospitalisation
To claim this facility, follow these steps prior to the cashless hospitalisation process:
- First, show your health insurance card at the hospital.
- The insurance desk will provide a pre-authorisation form. Fill it up and submit it.
- If you cannot wait for TPA approval, pay your bills to reimburse them later.
- During a medical emergency, a TPA processes claims within 6 hours.
Cashless Healthcare Plan Exclusions
There are, however, a few facilities that are not covered under cashless healthcare plans. A few of these are as follows:
- Ambulance charges
- Visitor or attendant fees
- Service charges
- Oxygen mask charges, nebuliser expenses, diaper expenses, etc.
- Toiletries expenses
- Documentation expenses
- Injuries caused due to terrorism, drug abuse, or alcohol
Reasons for Claim Rejection
Cashless claims can sometimes get rejected, barring an insured person from seeking treatment. Following are a few instances wherein a cashless claim can get rejected:
- If your ailment does not fall under your policy coverage
- In case your sum insured amount limit has been exhausted
- On account of inadequate information on the pre-authorisation form
- If the information provided is not sufficient
- Delay in informing your TPA about hospitalisation
However, there is a judgment from the Bombay High Court that TPAs will not reject or partially disallow claims. The onus lies entirely on the insurer. Previously, TPAs got paid incentives to deny any claim. But with this judgment, an insured will now get penalised with regards to claims.
Things to Remember before Purchasing a Cashless Health Plan
There are a few pointers that you must remember before choosing any health plan. Check them below:
- This benefit is only available at network hospitals.
- Only your hospital can justify your treatment.
- Keep a copy (photocopy) of all bills, reports, claim forms, discharge papers, and other documents.
- Make sure to read the fine print before purchasing.
Check the sum insured amount before buying cashless health insurance. A policyholder must pay any excess amount of expenses breaching the limit
